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Ashina M, Cohen JM, Galic M, Campos VR, Barash S, Ning X, Kessler Y, Janka L, Diener HC. Efficacy and safety of fremanezumab in patients with episodic and chronic migraine with documented inadequate response to 2 to 4 classes of migraine preventive medications over 6 months of treatment in the phase 3b FOCUS study. J Headache Pain 2021; 22:68. [PMID: 34246226 PMCID: PMC8272284 DOI: 10.1186/s10194-021-01279-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 06/11/2021] [Indexed: 12/17/2022] Open
Abstract
Background Fremanezumab, a fully humanized monoclonal antibody (IgG2Δa) selectively targets the calcitonin gene-related peptide and has proven efficacy for the preventive treatment of migraine. In this study, we evaluated the long-term efficacy, safety, and tolerability of monthly and quarterly fremanezumab. Methods Episodic migraine and chronic migraine patients completing the 12-week double-blind period of the FOCUS trial entered the 12-week open-label extension and received 3 monthly doses of fremanezumab (225 mg). Changes from baseline in monthly migraine days, monthly headache days of at least moderate severity, days of acute headache medication use, days with photophobia/phonophobia, days with nausea or vomiting, disability scores, and proportion of patients achieving a ≥50% or ≥75% reduction in monthly migraine days were evaluated. Results Of the 807 patients who completed the 12-week double-blind treatment period and entered the open-label extension, 772 patients completed the study. In the placebo, quarterly fremanezumab, and monthly fremanezumab dosing regimens, respectively, patients had fewer average monthly migraine days (mean [standard deviation] change from baseline: − 4.7 [5.4]; − 5.1 [4.7]; − 5.5 [5.0]), monthly headache days of at least moderate severity (− 4.5 [5.0]; − 4.8 [4.5]; − 5.2 [4.9]), days per month of acute headache medication use (− 4.3 [5.2]; − 4.9 [4.6]; − 4.8 [4.9]), days with photophobia/phonophobia (− 3.1 [5.3]; − 3.4 [5.3]; − 4.0 [5.2]), and days with nausea or vomiting (− 2.3 [4.6]; − 3.1 [4.5]; − 3.0 [4.4]). During the 12-week open-label extension, 38%, 45%, and 46% of patients, respectively, achieved a ≥50% reduction and 16%, 15%, and 20%, respectively, achieved a ≥75% reduction in monthly migraine days. Disability scores were substantially improved in all 3 treatment groups. There were low rates of adverse events leading to discontinuation (<1%). Conclusion Fremanezumab demonstrated sustained efficacy up to 6 months and was well tolerated in patients with episodic migraine or chronic migraine and documented inadequate response to multiple migraine preventive medication classes. Trial registration ClinicalTrials.gov NCT03308968 (FOCUS).
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Affiliation(s)
- Messoud Ashina
- Department of Neurology, Danish Headache Center, Rigshospitalet Glostrup, University of Copenhagen, Valdemar Hansens Vej 5, DK-2600 Glostrup, Copenhagen, Denmark.
| | - Joshua M Cohen
- Teva Branded Pharmaceutical Products R&D, Inc., West Chester, PA, USA
| | - Maja Galic
- Teva Pharmaceuticals, Amsterdam, The Netherlands
| | | | - Steve Barash
- Teva Branded Pharmaceutical Products R&D, Inc., West Chester, PA, USA
| | - Xiaoping Ning
- Teva Branded Pharmaceutical Products R&D, Inc., West Chester, PA, USA
| | - Yoel Kessler
- Teva Branded Pharmaceutical Products R&D, Inc., West Chester, PA, USA
| | - Lindsay Janka
- Teva Branded Pharmaceutical Products R&D, Inc., West Chester, PA, USA
| | - Hans-Christoph Diener
- Institute for Medical Informatics, Biometry and Epidemiology, Medical Faculty of the University Duisburg-Essen, Essen, Germany
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52
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Joshi S, Tepper SJ, Lucas S, Rasmussen S, Nelson R. A narrative review of the importance of pharmacokinetics and drug-drug interactions of preventive therapies in migraine management. Headache 2021; 61:838-853. [PMID: 34214182 PMCID: PMC8361687 DOI: 10.1111/head.14135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 04/09/2021] [Accepted: 04/12/2021] [Indexed: 12/28/2022]
Abstract
Objective To review the pharmacokinetics of major classes of migraine preventives and the clinical implications of drug–drug interactions (DDIs) with the use of these therapies in migraine management. Background Preventive treatments for migraine are recommended for a large proportion of patients with frequent migraine attacks. These patients often exhibit a number of comorbidities, which may lead to the introduction of multiple concomitant therapies. Potential DDIs must be considered when using polytherapy to avoid increased risk of adverse events (AEs) or inadequate treatment of comorbid conditions. Methods A literature search was performed to identify pharmacokinetic properties and potential DDIs of beta‐blockers, antiepileptic drugs, antidepressants, calcium channel blockers, gepants, and monoclonal antibody therapies targeting the calcitonin gene‐related peptide pathway with medications that may be used for comorbid conditions. Results Most DDIs occur through alterations in cytochrome P450 isoenzyme activity and may be complicated by genetic polymorphism for metabolic enzymes. Additionally, drug metabolism may be altered by grapefruit juice ingestion and smoking. The use of migraine preventive therapies may exacerbate symptoms of comorbid conditions or increase the risk of AEs associated with comorbid conditions as a result of DDIs. Conclusions DDIs are important to consider in patients with migraine who use multiple medications. The development of migraine‐specific evidence‐based preventive treatments allows for tailored clinical management that reduces the risk of DDIs and associated AEs in patients with comorbidities.
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Affiliation(s)
- Shivang Joshi
- Neurology/Headache Medicine, DENT Neurologic Institute, Amherst, NY, USA
| | - Stewart J Tepper
- Department of Neurology, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Sylvia Lucas
- Department of Neurology, University of Washington Medical Centers, Seattle, WA, USA
| | | | - Rob Nelson
- Global Medical, Amgen Inc., Thousand Oaks, CA, USA.,US Medical Affairs, Amgen Inc., Thousand Oaks, CA, USA
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53
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Barbanti P, Fofi L, Grazzi L, Vernieri F, Camarda C, Torelli P, Cevoli S, Russo A, Bono F, Finocchi C, Rao R, Messina S, De Simone R, Vanacore N, Bonassi S. Clinical features, disease progression, and use of healthcare resources in a large sample of 866 patients from 24 headache centers: A real-life perspective from the Italian chROnic migraiNe (IRON) project. Headache 2021; 61:936-950. [PMID: 34125953 DOI: 10.1111/head.14123] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 02/19/2021] [Accepted: 03/05/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To develop a dedicated Italian chronic migraine (CM) database (IRON project) to overcome disease misconceptions, improve clinical administration, reduce patients' burden, and rationalize economic resource allotment. BACKGROUND Proper CM management requires a comprehensive appraisal of its full clinical, social, and economic complexity. METHODS In this cross-sectional study, CM patients were screened in 24 certified headache centers with face-to-face interviews. Information on sociodemographic factors, medical history, characteristics of CM, and of prior episodic migraine (EM), and healthcare resource use was gathered using a semistructured web-based questionnaire. RESULTS A total of 866 CM patients were enrolled. CM started ~20 years after EM onset (age at EM onset 17.4 ± 9.1 vs. age at CM onset 35.3 ± 12.5 [mean ± SD]). CM prophylaxis, used by 430/866 (49.6%) of the patients, was often ineffective, not tolerated, and prematurely discontinued. Medications and diagnostic workup, frequently inappropriate, were mostly subsidized by the Italian national health service. CM patients with ≥25 headache days/month revealed substantial clinical differences and heavier disability and economic burden compared with those with <25 headache days/month. CONCLUSIONS CM is a heterogeneous headache disorder deserving more in-depth clinical characterization, sharper diagnostic criteria, and tailored treatments. CM registries are expected to improve clinical management, resulting in increased disease awareness, better healthcare resource allocation, and reduced economic burden.
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Affiliation(s)
- Piero Barbanti
- Headache and Pain Unit, IRCCS San Raffaele Pisana, Rome, Italy.,San Raffaele University, Rome, Italy
| | - Luisa Fofi
- Headache and Pain Unit, IRCCS San Raffaele Pisana, Rome, Italy
| | - Licia Grazzi
- Neuroalgology Unit, Headache Center Fondazione IRCCS Istituto Neurologico "Carlo Besta", Milan, Italy
| | - Fabrizio Vernieri
- Headache and Neurosonology Unit, Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Cecilia Camarda
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (BIND), University of Palermo, Palermo, Italy
| | - Paola Torelli
- Department of Medicine and Surgery, University of Parma, Parma, Italy.,Headache Center, Unit of Neurology, Azienda Ospedaliera-Universitaria of Parma, Parma, Italy
| | - Sabina Cevoli
- IRCCS Istituto delle Scienze Neurologiche, Bologna, Italy
| | - Antonio Russo
- Headache Center, Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Francesco Bono
- Headache Center, Neurology Unit A.O.U. Mater Domini, Catanzaro, Italy
| | | | - Renata Rao
- Headache Center, Department of Neurological Sciences and of Vision, Spedali Civili, Brescia, Italy
| | - Stefano Messina
- Department of Neurology-Stroke Unit, Laboratory of Neuroscience, Istituto Auxologico Italiano, IRCCS, Milano, Italy
| | - Roberto De Simone
- Headache Center, Department of Neuroscience, Reproductive Sciences and Dentistry, University Federico II of Naples, Naples, Italy
| | - Nicola Vanacore
- National Centre for Disease Prevention and Health Promotion, National Institute of Health, Roma, Italy
| | - Stefano Bonassi
- Unit of Clinical and Molecular Epidemiology, IRCCS San Raffaele Pisana, Roma, Italy
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Garelja ML, Walker CS, Hay DL. CGRP receptor antagonists for migraine. Are they also AMY 1 receptor antagonists? Br J Pharmacol 2021; 179:454-459. [PMID: 34076887 DOI: 10.1111/bph.15585] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 05/04/2021] [Accepted: 05/24/2021] [Indexed: 01/13/2023] Open
Abstract
The development of several drugs that target the calcitonin gene-related peptide (CGRP) system has been a major breakthrough in the pharmacological management of migraine. These are divided into two major classes, antibodies which bind to the CGRP peptide, preventing it from activating CGRP receptors and receptor antagonists. Within the receptor antagonist class, there are two mechanisms of action, small molecule receptor antagonists and an antibody antagonist. This mini-review considers the pharmacology of these receptor targeted antagonist drugs at the CGRP receptor and closely related AMY1 receptor, at which CGRP may also act. The antagonists are most potent at the CGRP receptor but can also show antagonism of the AMY1 receptor. However, important data are missing and selectivity parameters cannot be provided for all antagonists. The clinical implications of AMY1 receptor antagonism are unknown, but we urge consideration of this receptor as a potential contributing factor to CGRP and antagonist drug actions.
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Affiliation(s)
- Michael L Garelja
- Department of Pharmacology and Toxicology, University of Otago, Dunedin, New Zealand
| | - Christopher S Walker
- School of Biological Sciences, University of Auckland, Auckland, New Zealand.,Maurice Wilkins Centre for Molecular Biodiscovery, University of Auckland, Auckland, New Zealand
| | - Debbie L Hay
- Department of Pharmacology and Toxicology, University of Otago, Dunedin, New Zealand.,Maurice Wilkins Centre for Molecular Biodiscovery, University of Auckland, Auckland, New Zealand
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55
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Joyner KR, Morgan KW. Novel Therapies in Acute Migraine Management: Small-Molecule Calcitonin Gene-Receptor Antagonists and Serotonin 1F Receptor Agonist. Ann Pharmacother 2021; 55:745-759. [PMID: 32993366 DOI: 10.1177/1060028020963574] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To review the efficacy, safety, and cost of 3 newly approved agents-ubrogepant, lasmiditan, and rimegepant-representing 2 therapeutic classes, calcitonin gene-related peptide (CGRP) receptor antagonist and serotonin 1F (5-HT1F) agonists, for the acute treatment of migraine with or without aura. DATA SOURCES The Institute of Health US National Library of Medicine Clinical Trials, PubMed, and Cochrane databases were queried. Abstracts, journal articles, and other relevant sources published or present were reviewed. Search terms included the following: ubrogepant, MK-1602, Ubrelvy®, rimegepant, Nurtec®, BHV-3000, BMS-927711, lasmiditan, Reyvow®, LY573144. STUDY SELECTION AND DATA EXTRACTION Relevant English-language articles from June 30, 2010, to August 31, 2020, were evaluated and included in the narrative. DATA SYNTHESIS CGRP receptor antagonists, ubrogepant and rimegepant, achieved 2-hour pain freedom and freedom from the most bothersome migraine symptom (MBS) at 2 hours. Both agents were well tolerated, with adverse effects similar to placebo. Lasmiditan, a 5-HT1F receptor antagonist, also improved 2-hour pain freedom and freedom from the MBS at 2 hours. Lasmiditan is associated with dizziness, paresthesia, somnolence, nausea, fatigue, and lethargy. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE Ubrogepant, rimegepant, and lasmiditan represent a new and exciting chapter in acute migraine therapy. To date, no head-to-head studies have compared these agents with the triptans. Ubrogepant and lasmiditan are effective in triptan nonresponders. None of the 3 agents is contraindicated in cardiovascular disease, unlike the triptans. CONCLUSIONS Based on available data, ubrogepant, rimegepant, and lasmiditan should be reserved as second-line therapy and may be safe in patients with cardiovascular risk. Lasmiditan's adverse effect profile may limit its use.
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Affiliation(s)
- Kayla Rena Joyner
- Shenandoah University Bernard J. Dunn School of Pharmacy, Winchester, VA, USA
| | - Kelsey Woods Morgan
- Shenandoah University Bernard J. Dunn School of Pharmacy, Winchester, VA, USA
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56
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Zolmitriptan Intranasal Spanlastics for Enhanced Migraine Treatment; Formulation Parameters Optimized via Quality by Design Approach. Sci Pharm 2021. [DOI: 10.3390/scipharm89020024] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Zolmitriptan is a potent second-generation triptan prescribed for migraine attacks. It suffers low bioavailability (40%) after oral administration due to the hepatic first-pass metabolism. Spanlastics are surfactant-based elastic vesicular drug carrier systems. This study aimed to design and optimize intranasal spanlastic formulations as an alternative approach that directly targets brain delivery, enhancing its bioavailability and avoiding the first-pass effect. The quality by design approach was applied to correlate the formulation parameters (Span 60 and Tween 80 concentrations) and critical quality attributes (entrapment efficiency (EE%) and particle size). Spanlastic formulations were designed based on response surface central composite design and prepared via an ethanol injection method. Designed formulations were characterized by EE% and particle size measurements to select the optimized formula (with a combination of small particle size and high EE%). The optimized formula was further subjected to transmission electron microscopy, zeta potential measurement and ex vivo permeation study. The optimized formulation showed a particle size of 117.5 nm and EE% of 45.65%, with a low percentage of error between the observed and predicted values. Seventy percent of zolmitriptan was permeated through the nasal membrane within 30 min, and it completely permeated within 2 h with a significantly higher steady-state flux compared to plain gel. This study introduced a successful and promising intranasal formulation suitable for further brain delivery analysis.
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57
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Lipton RB, Burstein R, Buse DC, Dodick DW, Koukakis R, Klatt J, Cheng S, Chou DE. Efficacy of erenumab in chronic migraine patients with and without ictal allodynia. Cephalalgia 2021; 41:1152-1160. [PMID: 33982623 DOI: 10.1177/03331024211010305] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Ictal cutaneous allodynia, common in chronic migraine, is associated with reduced responses to acute treatment with triptans. Allodynia's impact on the efficacy of newer preventive treatments such as erenumab is unknown. METHODS Post-hoc subgroup analysis of a double-blind, randomized, placebo-controlled 12-week study of erenumab in chronic migraine, contrasting those with no allodynia with those with moderate-severe allodynia assessed with the Allodynia Symptom Checklist-12, was undertaken. RESULTS Of 648 randomized individuals with baseline Allodynia Symptom Checklist-12 scores, 386 (59.6%) had no allodynia and 153 (23.6%) had moderate-to-severe allodynia. Mean (standard deviation) baseline monthly migraine days were 17.6 (4.8) and 18.9 (4.3), respectively. Compared to placebo, the erenumab group had greater reductions in monthly migraine days and monthly acute migraine-specific medication days in both no allodynia and allodynia subgroups. Mean (95% confidence interval) treatment differences in change from baseline for monthly migraine days at week 12 were -2.5 (-3.7, -1.4) in the no allodynia subgroup and -3.3 (-5.3, -1.3) in the moderate-severe allodynia subgroup. Change in acute migraine-specific medication days were -3.3 (-4.3, -2.3) and -2.5 (-4.3, -0.8), respectively. CONCLUSIONS Erenumab's efficacy in reducing monthly migraine days and acute migraine-specific medication days in chronic migraine was not impacted by the presence of moderate-severe ictal allodynia.Trial registration: ClinicalTrials.gov NCT02066415.
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Affiliation(s)
- Richard B Lipton
- Albert Einstein College of Medicine, Bronx, NY, USA.,Montefiore Medical Center, Bronx, NY, USA
| | | | - Dawn C Buse
- Albert Einstein College of Medicine, Bronx, NY, USA
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58
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Luo G, Jiang XJ, Chen L, Conway CM, Gulianello M, Kostich W, Keavy D, Signor LJ, Chen P, Davis C, Whiterock VJ, Schartman R, Widmann KA, Macor JE, Dubowchik GM. Calcitonin gene-related peptide (CGRP) receptor antagonists: Heterocyclic modification of a novel azepinone lead. Bioorg Med Chem Lett 2021; 43:128077. [PMID: 33932522 DOI: 10.1016/j.bmcl.2021.128077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 04/19/2021] [Accepted: 04/25/2021] [Indexed: 11/19/2022]
Abstract
In our efforts to identify orally bioavailable CGRP receptor antagonists, we previously discovered a novel series of orally available azepinone derivatives that unfortunately also exhibited the unwanted property of potent time-dependent human CYP3A4 inhibition. Through heterocyclic replacement of the indazole ring, we discovered a series of heterocycle derivatives as high-affinity CGRP receptor antagonists. Some of them showed reasonable oral exposures, and the imidazolone derivatives that showed good oral exposure also exhibited substantially reduced time-dependent CYP3A4 inhibition. Several compounds showed strong in vivo efficacy in our marmoset facial blood flow assay with up to 87% inhibition of CGRP-induced activity. However, oral bioavailability generally remained low, emphasizing the challenges we and others encountered in discovering clinical development candidates for this difficult Class B GPCR target.
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Affiliation(s)
- Guanglin Luo
- Bristol-Myers Squibb, Wallingford, CT 06492, United States; Bristol Myers Squibb, Lawrenceville, NJ 08543, United States.
| | | | - Ling Chen
- Bristol-Myers Squibb, Wallingford, CT 06492, United States; Bristol Myers Squibb, Lawrenceville, NJ 08543, United States
| | - Charles M Conway
- Bristol-Myers Squibb, Wallingford, CT 06492, United States; Biohaven Pharmaceuticals Inc., New Haven, CT 06510, United States
| | - Michael Gulianello
- Bristol-Myers Squibb, Wallingford, CT 06492, United States; Sanofi, Framingham, MA 01701, United States
| | - Walter Kostich
- Bristol-Myers Squibb, Wallingford, CT 06492, United States; National Multiple Sclerosis Society, New York, NY 10017, United States
| | - Deborah Keavy
- Bristol-Myers Squibb, Wallingford, CT 06492, United States; Medtronic, North Haven, CT 06473, United States
| | - Laura J Signor
- Bristol-Myers Squibb, Wallingford, CT 06492, United States
| | - Ping Chen
- Bristol-Myers Squibb, Wallingford, CT 06492, United States; Bristol Myers Squibb, Lawrenceville, NJ 08543, United States
| | - Carl Davis
- Bristol-Myers Squibb, Wallingford, CT 06492, United States; Amgen, Inc. Thousand Oaks, CA 91320, United States
| | | | - Richard Schartman
- Bristol-Myers Squibb, Wallingford, CT 06492, United States; Preformulation Solutions, LLC, North Ridgeville, OH 44039, United States
| | | | - John E Macor
- Bristol-Myers Squibb, Wallingford, CT 06492, United States; Sanofi, Waltham, MA 02451, United States
| | - Gene M Dubowchik
- Bristol-Myers Squibb, Wallingford, CT 06492, United States; Biohaven Pharmaceuticals Inc., New Haven, CT 06510, United States
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59
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Capi M, De Angelis V, De Bernardini D, De Luca O, Cipolla F, Lionetto L, Simmaco M, Martelletti P. CGRP Receptor Antagonists and 5-HT1F Receptor Agonist in the Treatment of Migraine. J Clin Med 2021; 10:jcm10071429. [PMID: 33916043 PMCID: PMC8038117 DOI: 10.3390/jcm10071429] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 03/10/2021] [Accepted: 03/20/2021] [Indexed: 12/23/2022] Open
Abstract
Discovering that calcitonin-related peptide (CGRP) plays a key role in the complex pathophysiology of migraine has allowed us to make great strides in the development of new approaches for acute and preventive treatment. This evidence has led to the development of small molecules antagonist molecules of the CGRP receptor ("gepants") and of a new class of medications called "Ditans". This review presents the data from clinical trials reporting the efficacy, safety, and tolerability of the new drugs used in the treatment of migraines. Evidences show that therapeutic approaches targeted to CGRP have the potential to transform the clinical management of migraine, even though its appropriate place has yet to be determined with accuracy.
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Affiliation(s)
- Matilde Capi
- Laboratory of Clinical Biochemistry, Mass Spectrometry Unit, Sant’Andrea University Hospital, 00185 Rome, Italy; (M.C.); (D.D.B.); (L.L.); (M.S.)
| | - Valerio De Angelis
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, 00185 Rome, Italy; (V.D.A.); (F.C.)
| | - Donatella De Bernardini
- Laboratory of Clinical Biochemistry, Mass Spectrometry Unit, Sant’Andrea University Hospital, 00185 Rome, Italy; (M.C.); (D.D.B.); (L.L.); (M.S.)
| | - Ottavia De Luca
- Laboratory of Clinical Biochemistry, Advanced Molecular Diagnostic Unit, Sant’Andrea University Hospital, 00185 Rome, Italy;
| | - Fabiola Cipolla
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, 00185 Rome, Italy; (V.D.A.); (F.C.)
| | - Luana Lionetto
- Laboratory of Clinical Biochemistry, Mass Spectrometry Unit, Sant’Andrea University Hospital, 00185 Rome, Italy; (M.C.); (D.D.B.); (L.L.); (M.S.)
| | - Maurizio Simmaco
- Laboratory of Clinical Biochemistry, Mass Spectrometry Unit, Sant’Andrea University Hospital, 00185 Rome, Italy; (M.C.); (D.D.B.); (L.L.); (M.S.)
- Laboratory of Clinical Biochemistry, Advanced Molecular Diagnostic Unit, Sant’Andrea University Hospital, 00185 Rome, Italy;
- Department of Neurosciences, Mental Health and Sensory Organs (NESMOS), Sapienza University, 00185 Rome, Italy
| | - Paolo Martelletti
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, 00185 Rome, Italy; (V.D.A.); (F.C.)
- Correspondence:
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60
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Boinpally R, Jakate A, Butler M, Borbridge L, Periclou A. Single-Dose Pharmacokinetics and Safety of Atogepant in Adults With Hepatic Impairment: Results From an Open-Label, Phase 1 Trial. Clin Pharmacol Drug Dev 2021; 10:726-733. [PMID: 33501783 PMCID: PMC8359408 DOI: 10.1002/cpdd.916] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 12/28/2020] [Indexed: 01/26/2023]
Abstract
Atogepant is a selective oral calcitonin gene‐related peptide receptor antagonist in development for migraine prevention. Here, we report the pharmacokinetics (PK) and safety of single‐dose 60 mg atogepant in participants with severe, moderate, or mild hepatic impairment and matched participants with normal hepatic function from an open‐label, parallel‐group, single‐dose phase 1 trial. Thirty‐two participants aged 45 to 72 years were enrolled, which included 8 each with severe, moderate, mild, or no hepatic impairment. All participants completed the study. Atogepant was rapidly absorbed (median time to maximum plasma concentration, ∼2 hours) with an apparent terminal elimination half‐life of ∼11 hours. Compared with participants with normal hepatic function, the change in maximum plasma concentrations of atogepant were –4%, –12%, and +9% in participants with severe, moderate, or mild hepatic impairment, respectively. Overall systemic exposures to atogepant were 15% to 38% higher in participants with hepatic impairment compared with those with normal hepatic function, but these differences are not expected to be clinically relevant given the established safety profile of atogepant. Only 1 adverse event was reported: mild rhinorrhea in a participant with moderate hepatic impairment. Overall, atogepant was safe and not associated with any clinically relevant change in PK in participants with severe, moderate, or mild hepatic impairment.
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61
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Barbanti P, Aurilia C, Egeo G, Fofi L, Cevoli S, Colombo B, Filippi M, Frediani F, Bono F, Grazzi L, Salerno A, Mercuri B, Carnevale A, Altamura C, Vernieri F. Erenumab in the prevention of high-frequency episodic and chronic migraine: Erenumab in Real Life in Italy (EARLY), the first Italian multicenter, prospective real-life study. Headache 2020; 61:363-372. [PMID: 33337544 DOI: 10.1111/head.14032] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 08/14/2020] [Accepted: 08/15/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To assess the effectiveness, safety, and tolerability of erenumab in a real-life migraine population, while trying to identify responsiveness predictors. BACKGROUND Erenumab is a fully human Ig-2 monoclonal antibody blocking the calcitonin gene-related peptide receptor, indicated for migraine prophylaxis. Phase II and III trials demonstrated that erenumab is effective, safe, and well tolerated in the prevention of episodic and chronic migraine (CM), showing an early onset of action. METHODS This is a multicenter, prospective, cohort, and real-life study. We considered for enrolment all consecutive patients aged 18-65 affected by high-frequency episodic migraine (HFEM) or CM, with or without medication overuse, visited at nine Italian Headache Centers from December 20, 2018 to September 30, 2019. Each patient was treated with erenumab 70 mg, administered subcutaneously every 4 weeks. Treatment duration was planned to last from 6 to 12 months, depending on the patient's response. The primary endpoint was the change in monthly migraine days (MMDs) at weeks 9-12 compared to baseline. Secondary endpoints included changes in monthly analgesics intake, ≥50%, ≥75%, and 100% responder rates and any variation in the Visual Analog Scale (VAS) and Headache Impact Test scores (HIT). RESULTS In total, 372 migraine patients were treated with at least one dose of erenumab 70 mg. At weeks 9-12, erenumab decreased MMDs by 4.5 ± 4.1 days (mean ± SD) in patients with HFEM and by 9.3 ± 9.1 (mean ± SD) days in those with CM compared to baseline. At weeks 9-12 VAS score was reduced by 1.9 ± 1.9 (mean ± SD), HIT score by 10.7 ± 8.8 (mean ± SD), and median monthly analgesics intake passed from 12.0 (interquartile range [IQR] 10.0-14.0) to 5.0 (IQR 3.0-7.0) in HFEM. In CM patients, VAS was reduced by 1.7 ± 2.0 (mean ± SD), HIT by 9.7 ± 10.4 (mean ± SD), and median monthly analgesics intake passed from 20.0 (IQR 15.0-30.0) to 8.0 (IQR 5.0-15.0). At week 12, ≥50% responders were 60/101 (59.4%) for HFEM and 146/263 (55.5%) for CM, ≥75% responders were 17/101 (16.8%) and 59/263 (22.4%) and 100% responders 1/101 (1.0%) and 3/263 (1.1%), respectively. Erenumab responsiveness in HFEM was positively associated with unilateral pain localization (OR: 3.03, 95% CI: 1.24-7.40; p = 0.015), whereas in CM responsiveness was positively associated with and baseline migraine frequency (OR: 1.06, 95% CI:1.02-1.11; p = 0.031), dopaminergic symptoms (OR: 2.01, 95% CI: 1.14-3.52; p = 0.015), and negatively associated with psychiatric comorbidities (OR: 0.43, 95% CI: 0.20-0.93; p = 0.003). CONCLUSIONS Erenumab 70 mg is effective, safe, and well tolerated in real life. Easily obtainable clinical features might be of help in predicting patient's responsiveness.
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Affiliation(s)
- Piero Barbanti
- Headache and Pain Unit, IRCCS San Raffaele Pisana, Rome, Italy.,San Raffaele University, Rome, Italy
| | - Cinzia Aurilia
- Headache and Pain Unit, IRCCS San Raffaele Pisana, Rome, Italy
| | - Gabriella Egeo
- Headache and Pain Unit, IRCCS San Raffaele Pisana, Rome, Italy
| | - Luisa Fofi
- Headache and Pain Unit, IRCCS San Raffaele Pisana, Rome, Italy
| | - Sabina Cevoli
- IRCCS Istituto delle Scienze Neurologiche, Bologna, Italy
| | - Bruno Colombo
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Massimo Filippi
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | | | - Francesco Bono
- Center for Headache and Intracranial Pressure Disorders, Neurology Unit, A.O.U. Mater Domini, Catanzaro, Italy
| | - Licia Grazzi
- Neuroalgology Unit, Headache Center Fondazione IRCCS Istituto Neurologico "Carlo Besta", Milan, Italy
| | | | | | | | - Claudia Altamura
- Headache and Neurosonology Unit, Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Fabrizio Vernieri
- Headache and Neurosonology Unit, Policlinico Universitario Campus Bio-Medico, Rome, Italy
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Treatment of migraine: a review of disease burden and an update on the therapeutic landscape for pharmacists. DRUGS & THERAPY PERSPECTIVES 2020. [DOI: 10.1007/s40267-020-00801-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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63
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Headache in idiopathic intracranial hypertension. A CGRP-dependent head pain? Neurol Sci 2020; 41:417-421. [DOI: 10.1007/s10072-020-04641-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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64
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Ashina M, Doležil D, Bonner JH, Zhou L, Klatt J, Picard H, Mikol DD. A phase 2, randomized, double-blind, placebo-controlled trial of AMG 301, a pituitary adenylate cyclase-activating polypeptide PAC1 receptor monoclonal antibody for migraine prevention. Cephalalgia 2020; 41:33-44. [PMID: 33231489 PMCID: PMC7786389 DOI: 10.1177/0333102420970889] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Objective To assess the safety and efficacy of AMG 301, an inhibitor of the pituitary adenylate cyclase-activating polypeptide (PACAP)-1 (PAC1) receptor, for prevention of migraine. Methods In a double-blind trial, patients were randomized 4:3:3 to placebo, AMG 301 210 mg every 4 weeks, or AMG 301 420 mg every 2 weeks for 12 weeks. Effect on monthly migraine days and other secondary measures were assessed over weeks 9–12. Safety and tolerability were assessed. Results Of 343 randomized patients (mean age, 41.8–42.5 years), the majority were women (85.4–90.4%), white (94.1–96.2%), and had episodic migraine (62.5–67.9%). A total of 305 patients completed treatment (placebo, n = 124; AMG 301 210 mg, n = 94; AMG 301 420 mg, n = 87). Least squares mean reduction at week 12 in monthly migraine days from baseline was −2.5 (0.4) days for placebo and −2.2 (0.5) days for both AMG 301 treatment groups. No difference between AMG 301 and placebo on any measure of efficacy was observed; mean (95% confidence interval) treatment difference versus placebo for monthly migraine days for AMG 301 210 mg, 0.3 (−0.9 to 1.4); AMG 301 420 mg, 0.3 (−0.9 to 1.4). The incidence of adverse events was similar across groups. Conclusion AMG 301 offered no benefit over placebo for migraine prevention; further studies may be necessary to fully understand the role of PACAP isoforms and its receptors in migraine pathophysiology. Study Registration ClinicalTrials.gov: NCT03238781
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Affiliation(s)
- Messoud Ashina
- Danish Headache Center and Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - David Doležil
- Prague Headache Center, DADO MEDICAL sro, Prague, Czech Republic
| | | | | | - Jan Klatt
- Novartis Pharma AG, Basel, Switzerland
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65
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Melo-Carrillo A, Strassman AM, Schain AJ, Adams AM, Brin MF, Burstein R. Combined onabotulinumtoxinA/atogepant treatment blocks activation/sensitization of high-threshold and wide-dynamic range neurons. Cephalalgia 2020; 41:17-32. [PMID: 33200944 PMCID: PMC7786391 DOI: 10.1177/0333102420970507] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Background OnabotulinumtoxinA and agents that block calcitonin gene‒receptor peptide action have both been found to have anti-migraine effects, but they inhibit different populations of meningeal nociceptors. We therefore tested the effects of combined treatment with onabotulinumtoxinA and the calcitonin gene‒receptor peptide antagonist atogepant on activation/sensitization of trigeminovascular neurons by cortical spreading depression. Material and methods Single-unit recordings were obtained of high-threshold and wide-dynamic-range neurons in the spinal trigeminal nucleus, and cortical spreading depression was then induced in anesthetized rats that had received scalp injections of onabotulinumtoxinA 7 days earlier and intravenous atogepant infusion 1 h earlier. The control group received scalp saline injections and intravenous vehicle infusion. Results OnabotulinumtoxinA/atogepant pretreatment prevented cortical spreading depression-induced activation and sensitization in both populations (control: Activation in 80% of high-threshold and 70% of wide-dynamic-range neurons, sensitization in 80% of high-threshold and 60% of wide-dynamic-range neurons; treatment: activation in 10% of high-threshold and 0% of wide-dynamic-range neurons, sensitization in 0% of high-threshold and 5% of wide-dynamic-range neurons). Discussion We propose that the robust inhibition of high-threshold and wide-dynamic-range neurons by the combination treatment was achieved through dual blockade of the Aδ and C classes of meningeal nociceptors. Combination therapy that inhibits meningeal C-fibers and prevents calcitonin gene‒receptor peptide from activating its receptors on Aδ-meningeal nociceptors may be more effective than a monotherapy in reducing migraine days per month in patients with chronic migraine.
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Affiliation(s)
- Agustin Melo-Carrillo
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Anesthesia, Harvard Medical School, Boston, MA, USA
| | - Andrew M Strassman
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Anesthesia, Harvard Medical School, Boston, MA, USA
| | - Aaron J Schain
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Anesthesia, Harvard Medical School, Boston, MA, USA
| | | | - Mitchell F Brin
- Allergan, an AbbVie Company, Irvine, CA, USA
- University of California, Irvine, Irvine, CA, USA
| | - Rami Burstein
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Anesthesia, Harvard Medical School, Boston, MA, USA
- Rami Burstein, Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, CLS-649, 3 Blackfan Circle, Boston, MA 02215, USA.
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66
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Min KC, Kraft WK, Bondiskey P, Colón-González F, Liu W, Xu J, Panebianco D, Mixson L, Dockendorf MF, Matthews CZ, Boinpally R. Atogepant Is Not Associated With Clinically Meaningful Alanine Aminotransferase Elevations in Healthy Adults. Clin Transl Sci 2020; 14:599-605. [PMID: 33142014 PMCID: PMC7993278 DOI: 10.1111/cts.12917] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 10/04/2020] [Indexed: 11/26/2022] Open
Abstract
Atogepant is a potent, selective, oral calcitonin gene–related peptide (CGRP) receptor antagonist in development for migraine prevention. The chemical structure of atogepant is distinct from previous CGRP receptor antagonists, which were associated with elevated serum alanine aminotransferase (ALT) in clinical trials. Here, we report the safety, tolerability, and pharmacokinetics (PKs) of a once‐daily supratherapeutic dose (170 mg) of atogepant for 28 days from a randomized, double‐blind, placebo‐controlled phase I trial in healthy participants. Overall safety, hepatic safety, and plasma PK parameters were evaluated. Thirty‐four participants aged 23–55 years enrolled; 28 (82.4%) completed the study in accordance with the protocol. Multiple doses of 170 mg atogepant for 28 consecutive days were generally well‐tolerated. All adverse events (AEs; reported in 87.0% of the atogepant group; 72.7%, placebo) were mild in severity except one serious AE of subarachnoid hemorrhage due to a bicycle accident and not considered related to treatment. There were two discontinuations due to AEs, both with atogepant, one considered possibly related to treatment. Over 28 days of treatment, no participant receiving atogepant had an ALT elevation above 1.5 × upper limit of normal. Change from baseline in serum ALT levels was not different between atogepant and placebo. Atogepant is rapidly absorbed (median time to maximum plasma concentration, ~ 2 hours) with an apparent terminal half‐life of ~ 11 hours, and no evidence of accumulation after once‐daily dosing. Overall, atogepant at a high oral dose is safe and well‐tolerated in healthy participants with no clinically meaningful elevations in ALT.
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Affiliation(s)
- K Chris Min
- Formerly of Merck & Co., Inc., Kenilworth, New Jersey, USA
| | - Walter K Kraft
- Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | | | - Wen Liu
- Merck & Co., Inc., Kenilworth, New Jersey, USA
| | - Jialin Xu
- Formerly of Merck & Co., Inc., Kenilworth, New Jersey, USA
| | | | - Lori Mixson
- Formerly of Merck & Co., Inc., Kenilworth, New Jersey, USA
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67
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Swart ECS, Good CB, Henderson R, Manolis C, Yanta C, Parekh N, Neilson LM. Identifying Outcome Measures for Migraine Value-Based Contracting Using the Delphi Method. Headache 2020; 60:2139-2151. [PMID: 32997806 DOI: 10.1111/head.13978] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 08/05/2020] [Accepted: 08/06/2020] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To identify meaningful migraine outcome measures among key stakeholders to inform value-based contracts for migraine medications. BACKGROUND Value-based contracts linking medication payments to predefined performance metrics aim to promote value through aligned incentives and shared risk between manufacturers and payers. The emergence of new and expensive pharmaceuticals for migraine presents an opportunity for value-based contract development. However, uncertainty remains around which outcomes are most meaningful to all migraine stakeholders. METHODS This study utilized a Delphi survey to incorporate views from 82 stakeholders, including patients (n = 21), providers (n = 23), payers (n = 10), employers (n = 18), and pharmaceutical company representatives (n = 10). A list of 15 migraine-related outcomes was created from a literature review and subject matter expert consultation. Stakeholders reported on the value of these outcomes through a 5-point Likert scale and selection of their top 3 most meaningful outcomes. All participants except patients and employers also used a 5-point Likert scale to rate the feasibility of collecting each outcome measure. Consensus was defined as ≥75% agreement on the importance and feasibility of an outcome (Likert scores ≥4/5 or selection of an outcome as most meaningful). RESULTS After 2 rounds, consensus was achieved for importance of 9 outcomes on the Likert scale. "Decrease in migraine frequency" reached 100% agreement (82/82), followed by "increased ability to resume normal activities" (96%, 79/82). When asked to choose the 3 most meaningful outcomes, stakeholders selected "decrease in migraine frequency" (88%, 72/82) followed by "decrease in migraine severity" (80%, 66/82). The 2 measures rated as most feasibly collected were "decrease in emergency department/urgent care visits" (95%, 40/42) and "decrease in migraine frequency" (90%, 38/42). There were statistically significant differences between non-patient and patient stakeholders in selection of "decrease in emergency department/urgent care visits" [20% (12/61) vs 0% (0/21), P = .031]; and employer and patient stakeholders in selection of "decrease in work days missed" [44% (8/18) vs 5% (1/21), P = .006] and "decrease in emergency department/urgent care visits" [22% (4/18) vs 0% (0/21), P = .037] as most meaningful outcomes. CONCLUSIONS The measures "decrease in migraine frequency" followed by "decrease in migraine severity" were identified as top priority migraine outcome measures.
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Affiliation(s)
- Elizabeth C S Swart
- UPMC Centers for High-Value Health Care and Value-Based Pharmacy Initiatives, UPMC Health Plan, Pittsburgh, PA, USA
| | - Chester B Good
- UPMC Centers for High-Value Health Care and Value-Based Pharmacy Initiatives, UPMC Health Plan, Pittsburgh, PA, USA.,Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Chronis Manolis
- UPMC Centers for High-Value Health Care and Value-Based Pharmacy Initiatives, UPMC Health Plan, Pittsburgh, PA, USA
| | - Claire Yanta
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Lynn M Neilson
- UPMC Centers for High-Value Health Care and Value-Based Pharmacy Initiatives, UPMC Health Plan, Pittsburgh, PA, USA
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Smith B, Rowe J, Watkins PB, Ashina M, Woodhead JL, Sistare FD, Goadsby PJ. Mechanistic Investigations Support Liver Safety of Ubrogepant. Toxicol Sci 2020; 177:84-93. [PMID: 32579200 PMCID: PMC8312697 DOI: 10.1093/toxsci/kfaa093] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Small-molecule calcitonin gene-related peptide (CGRP) receptor antagonists have demonstrated therapeutic efficacy for the treatment of migraine. However, previously investigated CGRP receptor antagonists, telcagepant and MK-3207, were discontinued during clinical development because of concerns about drug-induced liver injury. A subsequent effort to identify novel CGRP receptor antagonists less likely to cause hepatotoxicity led to the development of ubrogepant. The selection of ubrogepant, following a series of mechanistic studies conducted with MK-3207 and telcagepant, was focused on key structural modifications suggesting that ubrogepant was less prone to forming reactive metabolites than previous compounds. The potential for each drug to cause liver toxicity was subsequently assessed using a quantitative systems toxicology approach (DILIsym) that incorporates quantitative assessments of mitochondrial dysfunction, disruption of bile acid homeostasis, and oxidative stress, along with estimates of dose-dependent drug exposure to and within liver cells. DILIsym successfully modeled liver toxicity for telcagepant and MK-3207 at the dosing regimens used in clinical trials. In contrast, DILIsym predicted no hepatotoxicity during treatment with ubrogepant, even at daily doses up to 1000 mg (10-fold higher than the approved clinical dose of 100 mg). These predictions are consistent with clinical trial experience showing that ubrogepant has lower potential to cause hepatotoxicity than has been observed with telcagepant and MK-3207.
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Affiliation(s)
| | | | - Paul B Watkins
- Eshelman School of Pharmacy and Institute for Drug Safety Sciences, University
of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Messoud Ashina
- Department of Neurology, Danish Headache Center, Faculty of Health and Medical
Sciences, University of Copenhagen, København, Denmark
| | | | | | - Peter J Goadsby
- NIHR-Wellcome Trust King’s Clinical Research Facility, SLaM Biomedical Research
Centre, King’s College London, London, UK
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69
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Monroe JJ, Tanis KQ, Podtelezhnikov AA, Nguyen T, Machotka SV, Lynch D, Evers R, Palamanda J, Miller RR, Pippert T, Cabalu TD, Johnson TE, Aslamkhan AG, Kang W, Tamburino AM, Mitra K, Agrawal NGB, Sistare FD. Application of a Rat Liver Drug Bioactivation Transcriptional Response Assay Early in Drug Development That Informs Chemically Reactive Metabolite Formation and Potential for Drug-induced Liver Injury. Toxicol Sci 2020; 177:281-299. [PMID: 32559301 PMCID: PMC7553701 DOI: 10.1093/toxsci/kfaa088] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Drug-induced liver injury is a major reason for drug candidate attrition from development, denied commercialization, market withdrawal, and restricted prescribing of pharmaceuticals. The metabolic bioactivation of drugs to chemically reactive metabolites (CRMs) contribute to liver-associated adverse drug reactions in humans that often goes undetected in conventional animal toxicology studies. A challenge for pharmaceutical drug discovery has been reliably selecting drug candidates with a low liability of forming CRM and reduced drug-induced liver injury potential, at projected therapeutic doses, without falsely restricting the development of safe drugs. We have developed an in vivo rat liver transcriptional signature biomarker reflecting the cellular response to drug bioactivation. Measurement of transcriptional activation of integrated nuclear factor erythroid 2-related factor 2 (NRF2)/Kelch-like ECH-associated protein 1 (KEAP1) electrophilic stress, and nuclear factor erythroid 2-related factor 1 (NRF1) proteasomal endoplasmic reticulum (ER) stress responses, is described for discerning estimated clinical doses of drugs with potential for bioactivation-mediated hepatotoxicity. The approach was established using well benchmarked CRM forming test agents from our company. This was subsequently tested using curated lists of commercial drugs and internal compounds, anchored in the clinical experience with human hepatotoxicity, while agnostic to mechanism. Based on results with 116 compounds in short-term rat studies, with consideration of the maximum recommended daily clinical dose, this CRM mechanism-based approach yielded 32% sensitivity and 92% specificity for discriminating safe from hepatotoxic drugs. The approach adds new information for guiding early candidate selection and informs structure activity relationships (SAR) thus enabling lead optimization and mechanistic problem solving. Additional refinement of the model is ongoing. Case examples are provided describing the strengths and limitations of the approach.
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Affiliation(s)
| | | | | | | | | | - Donna Lynch
- Safety Assessment & Laboratory Animal Resources
| | - Raymond Evers
- Pharmacokinetics, Pharmacodynamics & Drug Metabolism, Merck & Co., Inc, West Point, Pennsylvania 19486
| | - Jairam Palamanda
- Pharmacokinetics, Pharmacodynamics & Drug Metabolism, Merck & Co., Inc, West Point, Pennsylvania 19486
| | - Randy R Miller
- Pharmacokinetics, Pharmacodynamics & Drug Metabolism, Merck & Co., Inc, West Point, Pennsylvania 19486
| | | | - Tamara D Cabalu
- Pharmacokinetics, Pharmacodynamics & Drug Metabolism, Merck & Co., Inc, West Point, Pennsylvania 19486
| | | | | | - Wen Kang
- Safety Assessment & Laboratory Animal Resources
| | | | - Kaushik Mitra
- Safety Assessment & Laboratory Animal Resources
- Janssen Research & Development, LLC, Spring House, PA 19486
| | - Nancy G B Agrawal
- Pharmacokinetics, Pharmacodynamics & Drug Metabolism, Merck & Co., Inc, West Point, Pennsylvania 19486
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Pan KS, Siow A, Hay DL, Walker CS. Antagonism of CGRP Signaling by Rimegepant at Two Receptors. Front Pharmacol 2020; 11:1240. [PMID: 32973499 PMCID: PMC7468408 DOI: 10.3389/fphar.2020.01240] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 07/29/2020] [Indexed: 01/29/2023] Open
Abstract
The “gepants” are a class of calcitonin gene-related peptide (CGRP) receptor antagonist molecules that have been developed for the prevention and treatment of migraine. Rimegepant is reported to act at the CGRP receptor, has good oral bioavailability, and has had positive clinical trial results. However, there is very little data available describing its receptor pharmacology. Importantly, rimegepant activity at the AMY1 receptor, a second potent CGRP receptor that is known to be expressed in the trigeminovascular system, has not been reported. The ability of rimegepant to antagonize activation of human CGRP, AMY1, and related adrenomedullin receptors was determined in transfected in Cos7 cells. Rimegepant was an effective antagonist at both the CGRP and AMY1 receptor. The antagonism of both CGRP and AMY1 receptors may have implications for our understanding of the mechanism of action of rimegepant in the treatment of migraine.
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Affiliation(s)
- Kylie S Pan
- School of Biological Sciences, University of Auckland, Auckland, New Zealand
| | - Andrew Siow
- School of Chemical Sciences, University of Auckland, Auckland, New Zealand
| | - Debbie L Hay
- School of Biological Sciences, University of Auckland, Auckland, New Zealand.,Centre for Brain Research, University of Auckland, Auckland, New Zealand.,Maurice Wilkins Centre for Molecular Biodiscovery, University of Auckland, Auckland, New Zealand.,Department of Pharmacology and Toxicology, University of Otago, Dunedin, New Zealand
| | - Christopher S Walker
- School of Biological Sciences, University of Auckland, Auckland, New Zealand.,Centre for Brain Research, University of Auckland, Auckland, New Zealand.,Maurice Wilkins Centre for Molecular Biodiscovery, University of Auckland, Auckland, New Zealand
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Mulder IA, Li M, de Vries T, Qin T, Yanagisawa T, Sugimoto K, van den Bogaerdt A, Danser AHJ, Wermer MJH, van den Maagdenberg AMJM, MaassenVanDenBrink A, Ferrari MD, Ayata C. Anti-migraine Calcitonin Gene-Related Peptide Receptor Antagonists Worsen Cerebral Ischemic Outcome in Mice. Ann Neurol 2020; 88:771-784. [PMID: 32583883 PMCID: PMC7540520 DOI: 10.1002/ana.25831] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 06/11/2020] [Accepted: 06/21/2020] [Indexed: 12/31/2022]
Abstract
Objective Calcitonin gene–related peptide (CGRP) pathway inhibitors are emerging treatments for migraine. CGRP‐mediated vasodilation is, however, a critical rescue mechanism in ischemia. We, therefore, investigated whether gepants, small molecule CGRP receptor antagonists, worsen cerebral ischemia. Methods Middle cerebral artery was occluded for 12 to 60 minutes in mice. We compared infarct risk and volumes, collateral flow, and neurological deficits after pretreatment with olcegepant (single or 10 daily doses of 0.1–1mg/kg) or rimegepant (single doses of 10–100mg/kg) versus vehicle. We also determined their potency on CGRP‐induced relaxations in mouse and human vessels, in vitro. Results Olcegepant (1mg/kg, single dose) increased infarct risk after 12‐ to 20‐minute occlusions mimicking transient ischemic attacks (14/19 vs 6/18 with vehicle, relative risk = 2.21, p < 0.022), and doubled infarct volumes (p < 0.001) and worsened neurological deficits (median score = 9 vs 5 with vehicle, p = 0.008) after 60‐minute occlusion. Ten daily doses of 0.1 to 1mg/kg olcegepant yielded similar results. Rimegepant 10mg/kg increased infarct volumes by 60% after 20‐minute ischemia (p = 0.03); 100mg/kg caused 75% mortality after 60‐minute occlusion. In familial hemiplegic migraine type 1 mice, olcegepant 1mg/kg increased infarct size after 30‐minute occlusion (1.6‐fold, p = 0.017). Both gepants consistently diminished collateral flow and reduced reperfusion success. Olcegepant was 10‐fold more potent than rimegepant on CGRP‐induced relaxations in mouse aorta. Interpretation Gepants worsened ischemic stroke in mice via collateral dysfunction. CGRP pathway blockers might thus aggravate coincidental cerebral ischemic events. The cerebrovascular safety of these agents must therefore be better delineated, especially in patients at increased risk of ischemic events or on prophylactic CGRP inhibition. ANN NEUROL 2020;88:771–784
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Affiliation(s)
- Inge A Mulder
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mei Li
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Tessa de Vries
- Division of Pharmacology and Vascular Medicine, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Tao Qin
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Takeshi Yanagisawa
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kazutaka Sugimoto
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - A H Jan Danser
- Division of Pharmacology and Vascular Medicine, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Marieke J H Wermer
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | - Arn M J M van den Maagdenberg
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands.,Department of Human Genetics, Leiden University Medical Center, Leiden, the Netherlands
| | - Antoinette MaassenVanDenBrink
- Division of Pharmacology and Vascular Medicine, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Michel D Ferrari
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | - Cenk Ayata
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Zhao YJ, Ho KH, Wong PS. Early clinical experience with a monoclonal antibody against the calcitonin gene-related peptide receptor in adolescents with migraine: A case series. PROCEEDINGS OF SINGAPORE HEALTHCARE 2020. [DOI: 10.1177/2010105820935465] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Management of migraine in adolescents poses a great challenge, as many of the approved pharmacological migraine preventive agents have age restrictions. Following favorable safety and efficacy reports of the new class agent calcitonin gene-related peptide (CGRP) monoclonal antibody for use in migraine prevention, there is growing interest in its application in pediatric migraine. We present here a case series detailing our experience of using erenumab, a CGRP monoclonal antibody, in six adolescent patients. Two patients had a reduction of at least 50% in the mean number of monthly migraine days, one patient reported subjective improvement, while three patients did not respond to the first dose of erenumab and discontinued treatment. One patient reported constipation associated with erenumab use. We speculate that CGRP monoclonal antibody could potentially be a viable option in adolescent patients with migraine. Further evidences that support efficacy and safety of erenumab in this group is needed.
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Affiliation(s)
- Yi Jing Zhao
- Department of Neurology, National Neuroscience Institute – Singapore General Hospital Campus, Singapore
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73
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Abstract
Migraine is the leading cause of years lost due to disability in individuals aged 15 to 49 years. Much has changed over the last three decades about our understanding of this complex neurological disorder. Various phases of migraine have been characterized and are the focus of this review. The premonitory phase involves bothersome symptoms experienced hours to days before migraine pain. Behavioral changes and functional neuroimaging studies point toward hypothalamic involvement during the premonitory and other migraine phases. Migraine aura is a disruptive, reversible neurological phenomenon that affects up to one-third of all migraineurs, and can overlap with the headache phase. The mechanism responsible for this phase is thought to be cortical spreading depolarization through the cortex. This process leads to temporary disruptions in ion homeostasis and the ensuing neuronal dysfunction. The headache phase involves activation of the trigeminocervical complex. Neuropeptides are implicated in trigeminal activation, and calcitonin gene-related peptide in particular has become a promising target of therapeutic intervention for migraine. The final phase of migraine is the postdrome, the period of time from the resolution of headache symptoms until return to baseline following a migraine. People often report neuropsychiatric, sensory, gastrointestinal, and general symptoms during this time, which can limit activity. Elucidating the neuroanatomical, chemical, and neuroimaging correlates of these migraine phases allows for an improved comprehension of the underlying changes associated with migraine symptomatology and can assist with evaluation of arising therapeutics for migraine management.
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Affiliation(s)
- William Qubty
- Pediatric Headache Center, Department of Neurology, Dell Medical School at the University of Texas at Austin, Austin, Texas.
| | - Irene Patniyot
- Department of Pediatric Neurology and Developmental Neuroscience, Baylor College of Medicine, Houston, Texas
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74
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Christensen SL, Munro G, Petersen S, Shabir A, Jansen-Olesen I, Kristensen DM, Olesen J. ATP sensitive potassium (K ATP) channel inhibition: A promising new drug target for migraine. Cephalalgia 2020; 40:650-664. [PMID: 32418458 DOI: 10.1177/0333102420925513] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Recently, the adenosine triphosphate (ATP) sensitive potassium channel opener levcromakalim was shown to induce migraine attacks with a far higher incidence than any previous provoking agent such as calcitonin gene-related peptide. Here, we show efficacy of ATP sensitive potassium channel inhibitors in two validated rodent models of migraine. METHODS In female spontaneous trigeminal allodynic rats, the sensitivity of the frontal region of the head was tested by an electronic von Frey filament device. In mice, cutaneous hypersensitivity was induced by repeated glyceryl trinitrate or levcromakalim injections over nine days, as measured with von Frey filaments in the hindpaw. Release of calcitonin gene-related peptide from dura mater and trigeminal ganglion was studied ex vivo. RESULTS The ATP sensitive potassium channel inhibitor glibenclamide attenuated the spontaneous cephalic hypersensitivity in spontaneous trigeminal allodynic rats and glyceryl trinitrate-induced hypersensitivity of the hindpaw in mice. It also inhibited CGRP release from dura mater and the trigeminal ganglion isolated from spontaneous trigeminal allodynic rats. The hypersensitivity was also diminished by the structurally different ATP sensitive potassium channel inhibitor gliquidone. Mice injected with the ATP sensitive potassium channel opener levcromakalim developed a progressive hypersensitivity that was completely blocked by glibenclamide, confirming target engagement. CONCLUSION The results suggest that ATP sensitive potassium channel inhibitors could be novel and highly effective drugs in the treatment of migraine.
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Affiliation(s)
- Sarah L Christensen
- Danish Headache Center, Department of Neurology, Glostrup Research Institute, Righospitalet Glostrup, Glostrup, Denmark
| | - Gordon Munro
- Danish Headache Center, Department of Neurology, Glostrup Research Institute, Righospitalet Glostrup, Glostrup, Denmark
| | - Steffen Petersen
- Danish Headache Center, Department of Neurology, Glostrup Research Institute, Righospitalet Glostrup, Glostrup, Denmark
| | - Anmool Shabir
- Danish Headache Center, Department of Neurology, Glostrup Research Institute, Righospitalet Glostrup, Glostrup, Denmark
| | - Inger Jansen-Olesen
- Danish Headache Center, Department of Neurology, Glostrup Research Institute, Righospitalet Glostrup, Glostrup, Denmark
| | - David M Kristensen
- Danish Headache Center, Department of Neurology, Glostrup Research Institute, Righospitalet Glostrup, Glostrup, Denmark.,Univ Rennes, Inserm, EHESP, Irset (Research Center for Environmental and Occupational Health), Rennes, France
| | - Jes Olesen
- Danish Headache Center, Department of Neurology, Glostrup Research Institute, Righospitalet Glostrup, Glostrup, Denmark
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75
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Zhao YJ, Ong JJY, Goadsby PJ. Emerging Treatment Options for Migraine. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2020. [DOI: 10.47102/annals-acadmed.sg.2019255] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Migraine is one of top 5 medical conditions that contribute to Years Lived with Disability and affects approximately 1 billion people from around the world. To date, preventive treatment and acute therapies for migraine are limited, have undesirable side effects and are poorly tolerated in patients. In the last few decades, considerable advances in our understanding of migraine and its pathophysiology have paved the way for the development of targeted treatment options. Calcitonin gene-related peptide (CGRP) plays an integral role in the neurobiology of migraine, and new classes of drugs that target the CGRP pathway have included gepants and CGRP pathway monoclonal antibodies. Serotonin 5-HT1F receptor agonists—namely ditans—have also been developed to treat acute migraine. Lastly, non-invasive neuromodulation offers another treatment option for migraine patients who prefer treatments that have fewer side effects and are well tolerated. In this review, we discussed emerging treatment options for migraine that were made available in recent years.
Ann Acad Med Singapore 2020;49:226–35
Key words: Calcitonin gene-related peptide monoclonal antibody, Gepants, Headache, Lasmiditan, Neuromodulation
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Affiliation(s)
- Yi Jing Zhao
- National Neuroscience Institute (Singapore General Hospital Campus), Singapore
| | - Jonathan JY Ong
- University Medicine Cluster, National University Hospital, Singapore
| | - Peter J Goadsby
- SLaM Biomedical Research Centre, King’s College, United Kingdom
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76
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Christensen SL, Ernstsen C, Olesen J, Kristensen DM. No central action of CGRP antagonising drugs in the GTN mouse model of migraine. Cephalalgia 2020; 40:924-934. [DOI: 10.1177/0333102420914913] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
IntroductionClinically, calcitonin gene-related peptide antagonising drugs are recognized as effective in migraine treatment, but their site of action is debated. Only a small fraction of these compounds pass the blood-brain barrier and accesses the central nervous system. Regardless, it has been argued that the central nervous system is the site of action. Here, we test this hypothesis by bypassing the blood-brain barrier through intracerebroventricular injection of calcitonin gene-related peptide antagonising drugs.MethodsWe used the glyceryl trinitrate (GTN) mouse model, which is well validated by its response to specific migraine drugs. The calcitonin gene-related peptide receptor antagonist olcegepant and the calcitonin gene-related peptide monoclonal antibody ALD405 were administered either intraperitoneally or intracerebroventricularly. The outcome measure was cutaneous mechanical allodynia.ResultsMice given olcegepant intraperitoneally + GTN on day 1 had a mean 50% withdrawal threshold of 1.2 g in contrast to mice receiving placebo + GTN, which had a threshold of 0.3 g ( p < 0.001). Similarly, in the ALD405 + GTN group, mice had thresholds of 1.2 g versus 0.2 g in the placebo + GTN group ( p < 0.001). However, both drugs were ineffective when delivered intracerebroventricularly, as control and active groups had identical mechanical sensitivity thresholds, 0.2 g versus 0.1 g and 0.1 g versus 0.1 g for olcegepant and ALD405, respectively ( p > 0.99 in both cases).DiscussionThe site of action of olcegepant and of the monoclonal antibody ALD405 is outside the blood-brain barrier in this mouse model of migraine. It is likely that these results can be generalised to all gepants and all antibodies and that the results are relevant for human migraine.
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Affiliation(s)
- Sarah L Christensen
- Danish Headache Center, Glostrup Research Institute, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Charlotte Ernstsen
- Danish Headache Center, Glostrup Research Institute, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Jes Olesen
- Danish Headache Center, Glostrup Research Institute, Rigshospitalet Glostrup, Glostrup, Denmark
| | - David M Kristensen
- Danish Headache Center, Glostrup Research Institute, Rigshospitalet Glostrup, Glostrup, Denmark
- University of Rennes, Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail) – UMR_S 1085, Rennes, France
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Abstract
Objective: To review specific literature that aimed to predict the future of US pharmacy, beginning in the late 1980s. Data Sources: Articles were identified from searching MEDLINE, CINAHL, Google Scholar, and references of relevant articles. The following combinations of search terms were used: future, pharmacy, prediction, and forecast. Study Selection and Data Extraction: The following inclusion criteria were applied: (1) full-text commentary, review, or original research and (2) focused predominantly on the pharmacy in the United States. Data on predictions for the future of pharmacy were extracted. Data Synthesis: We selected 3 articles published between 1988 and 2006, with each aiming to project the future for the following decade. We examined each prediction in light of the current knowledge. Relevance to Patient Care and Clinical Practice: Educators, practitioners, and other stakeholders should consider reflecting on the changes in pharmacy for the past 3 decades and applying both historical and emerging trends to improve patient care and sustain practice in the third decade of the 21st century and beyond. Conclusion: Most of the predictions for the future of pharmacy from the past 3 decades materialized, with some still in progress (reimbursement for pharmacy services), whereas others manifested in unexpected ways (transition from shortage to excess of pharmacists). Current forces shaping pharmacy include, but are not limited to, growing spending and use of specialty drugs, automation of pharmacy operations, growth of pharmacy in the digital health enterprise, and growing consumer interest in the use of analytical pharmacy that tests drugs before dispensing.
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78
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Dubowchik GM, Conway CM, Xin AW. Blocking the CGRP Pathway for Acute and Preventive Treatment of Migraine: The Evolution of Success. J Med Chem 2020; 63:6600-6623. [PMID: 32058712 DOI: 10.1021/acs.jmedchem.9b01810] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The pivotal role of calcitonin gene-related peptide (CGRP) in migraine pathophysiology was identified over 30 years ago, but the successful clinical development of targeted therapies has only recently been realized. This Perspective traces the decades long evolution of medicinal chemistry required to advance small molecule CGRP receptor antagonists, also called gepants, including the current clinical agents rimegepant, vazegepant, ubrogepant, and atogepant. Providing clinically effective blockade of CGRP signaling required surmounting multiple challenging hurdles, including defeating a sizable ligand with subnanomolar affinity for its receptor, designing antagonists with an extended confirmation and multiple pharmacophores while retaining solubility and oral bioavailability, and achieving circulating free plasma levels that provided near maximal CGRP receptor coverage. The clinical efficacy of oral and intranasal gepants and the injectable CGRP monoclonal antibodies (mAbs) are described, as are recent synthetic developments that have benefited from new structural biology data. The first oral gepant was recently approved and heralds a new era in the treatment of migraine.
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Affiliation(s)
- Gene M Dubowchik
- Biohaven Pharmaceuticals Inc., 215 Church Street, New Haven, Connecticut 06510, United States
| | - Charles M Conway
- Biohaven Pharmaceuticals Inc., 215 Church Street, New Haven, Connecticut 06510, United States
| | - Alison W Xin
- Biohaven Pharmaceuticals Inc., 215 Church Street, New Haven, Connecticut 06510, United States
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79
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Della Pietra A, Mikhailov N, Giniatullin R. The Emerging Role of Mechanosensitive Piezo Channels in Migraine Pain. Int J Mol Sci 2020; 21:ijms21030696. [PMID: 31973098 PMCID: PMC7037473 DOI: 10.3390/ijms21030696] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 01/11/2020] [Accepted: 01/19/2020] [Indexed: 12/18/2022] Open
Abstract
Recently discovered mechanosensitive Piezo channels emerged as the main molecular detectors of mechanical forces. The functions of Piezo channels range from detection of touch and pain, to control of the plastic changes in different organs. Recent studies suggested the role of Piezo channels in migraine pain, which is supposed to originate from the trigeminovascular nociceptive system in meninges. Interestingly, migraine pain is associated with such phenomenon as mechanical hypersensitivity, suggesting enhanced mechanotransduction. In the current review, we present the data that propose the implication of Piezo channels in migraine pain, which has a distinctive pulsatile character. These data include: (i) distribution of Piezo channels in the key elements of the trigeminovascular nociceptive system; (ii) the prolonged functional activity of Piezo channels in meningeal afferents providing a mechanistical basis for mechanotransduction in nociceptive nerve terminals; (iii) potential activation of Piezo channels by shear stress and pulsating blood flow; and (iv) modulation of these channels by emerging chemical agonists and modulators, including pro-nociceptive compounds. Achievements in this quickly expanding field should open a new road for efficient control of Piezo-related diseases including migraine and chronic pain.
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Affiliation(s)
- Adriana Della Pietra
- A. I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, 70211 Kuopio, Finland; (A.D.P.); (N.M.)
| | - Nikita Mikhailov
- A. I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, 70211 Kuopio, Finland; (A.D.P.); (N.M.)
| | - Rashid Giniatullin
- A. I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, 70211 Kuopio, Finland; (A.D.P.); (N.M.)
- Laboratory of Neurobiology, Kazan Federal University, 420008 Kazan, Russia
- Correspondence:
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Ankrom W, Bondiskey P, Li CC, Palcza J, Liu W, Dockendorf MF, Matthews C, Panebianco D, Reynders T, Wagner JA, Jakate A, Mesens S, Kraft WK, Marcantonio EE. Ubrogepant Is Not Associated With Clinically Meaningful Elevations of Alanine Aminotransferase in Healthy Adult Males. Clin Transl Sci 2020; 13:462-472. [PMID: 31899602 PMCID: PMC7214647 DOI: 10.1111/cts.12728] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 10/20/2019] [Indexed: 11/28/2022] Open
Abstract
Ubrogepant is a novel, oral calcitonin gene-related peptide (CGRP) receptor antagonist intended for the acute treatment of migraine attacks. Ubrogepant has a chemical structure distinct from previous small-molecule CGRP receptor antagonists that were associated with elevated serum alanine aminotransferase (ALT) in clinical trials. Here, we report overall and hepatic safety data from two placebo-controlled phase I trials of ubrogepant, spray-dried oral compressed tablet (SD-OCT) in healthy male volunteers. Trial A was a pharmacokinetic (PK) trial of single (100-400 mg) and multiple (40-400 mg) ascending doses. Trial B was a dedicated hepatic safety trial assessing daily use of ubrogepant 150 mg for 28 days. Serum ALT (as hepatotoxicity biomarker) and PK data are reported. Ubrogepant was well-tolerated in both trials, with a low incidence of adverse events that did not differ greatly from placebo. Changes in mean ALT levels were minimal and similar to placebo. Over 28 days of treatment, the mean percentage change in ALT from baseline was < 5% at all time points. No participant in either trial demonstrated ALT ≥ 3× upper limit of normal at any time. Ubrogepant SD-OCT demonstrated linear PK appropriate for acute treatment of migraine, with rapid uptake (time of maximum plasma concentration (tmax ): 2-3 hours) and no accumulation with daily use. Overall, there was no evidence of ubrogepant-associated hepatotoxicity with daily doses up to 400 mg for 10 days or with daily ubrogepant 150 mg for 28 days. Supratherapeutic dosing is a useful strategy for characterizing hepatic safety in early drug development.
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Affiliation(s)
- Wendy Ankrom
- Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, New Jersey, USA
| | - Phung Bondiskey
- Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, New Jersey, USA
| | - Chi-Chung Li
- Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, New Jersey, USA
| | - John Palcza
- Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, New Jersey, USA
| | - Wen Liu
- Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, New Jersey, USA
| | - Marissa F Dockendorf
- Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, New Jersey, USA
| | - Catherine Matthews
- Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, New Jersey, USA
| | - Deborah Panebianco
- Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, New Jersey, USA
| | | | - John A Wagner
- Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, New Jersey, USA
| | | | | | - Walter K Kraft
- Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Eugene E Marcantonio
- Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, New Jersey, USA
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Noseda R, Schain AJ, Melo-Carrillo A, Tien J, Stratton J, Mai F, Strassman AM, Burstein R. Fluorescently-labeled fremanezumab is distributed to sensory and autonomic ganglia and the dura but not to the brain of rats with uncompromised blood brain barrier. Cephalalgia 2019; 40:229-240. [PMID: 31856583 PMCID: PMC7233263 DOI: 10.1177/0333102419896760] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Background The presence of calcitonin gene-related peptide and its receptors in multiple brain areas and peripheral tissues previously implicated in migraine initiation and its many associated symptoms raises the possibility that humanized monoclonal anti-calcitonin gene-related peptide antibodies (CGRP-mAbs) can prevent migraine by modulating neuronal behavior inside and outside the brain. Critical to our ability to conduct a fair discussion over the mechanisms of action of CGRP-mAbs in migraine prevention is data generation that determines which of the many possible peripheral and central sites are accessible to these antibodies – a question raised frequently due to their large size. Material and methods Rats with uncompromised and compromised blood-brain barrier (BBB) were injected with Alexa Fluor 594-conjugated fremanezumab (Frema594), sacrificed 4 h or 7 d later, and relevant tissues were examined for the presence of Frema594. Results In rats with uncompromised BBB, Frema594 was similarly observed at 4 h and 7 d in the dura, dural blood vessels, trigeminal ganglion, C2 dorsal root ganglion, the parasympathetic sphenopalatine ganglion and the sympathetic superior cervical ganglion but not in the spinal trigeminal nucleus, thalamus, hypothalamus or cortex. In rats with compromised BBB, Frema594 was detected in the cortex (100 µm surrounding the compromised BBB site) 4 h but not 7 d after injections. Discussion Our inability to detect fluorescent (CGRP-mAbs) in the brain supports the conclusion that CGRP-mAbs prevent the headache phase of migraine by acting mostly, if not exclusively, outside the brain as the amount of CGRP-mAbs that enters the brain (if any) is too small to be physiologically meaningful.
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Affiliation(s)
- Rodrigo Noseda
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Aaron J Schain
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Agustin Melo-Carrillo
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston MA, USA.,Harvard Medical School, Boston, MA, USA
| | | | | | - Fanny Mai
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston MA, USA
| | - Andrew M Strassman
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Rami Burstein
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston MA, USA.,Harvard Medical School, Boston, MA, USA
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82
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Abstract
Introduction: Calcitonin Gene-Related Peptide (CGRP) plays a crucial role in migraine pathophysiology. A novel specific treatment strategy for the prevention of migraine incorporates monoclonal antibodies (mAbs) against CGRP and its canonical receptor. Eptinezumab, fremanezumab and galcanezumab block CGRP mediated effects by binding to the peptide, while erenumab blocks the CGRP receptor.Areas covered: Following a brief overview of pharmacological characteristics, we will review phase III trials for the use of CGRP mAbs in the prevention of episodic and chronic migraine.Expert opinion: All four CGRP mAbs demonstrated an excellent safety, tolerability and efficacy profile in migraine patients. Across all trials mAbs showed superior efficacy for the reduction of monthly migraine days compared to placebo with a net benefit of 2.8 days. Neither cardiovascular nor immunological safety concerns have emerged from clinical trials. Fremanezumab, galcanezumab, and erenumab are approved in the USA and Europe. Based on trial data there is no reason why these mAbs should not become first-line therapies in future. For now, we advocate for the use of mAbs in migraine prevention for patients who failed a minimum of two standard oral treatments based on the novelty and costs of this approach. mAbs are also effective in patients with medication overuse and with comorbid depression or anxiety disorders. Taken together, mAbs are likely to usher in a new era in migraine prevention and provide significant value to patients.
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Affiliation(s)
- Bianca Raffaelli
- Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany.,Clinician Scientist Programm, Berlin Institute of Health (BIH), Berlin, Germany
| | - Lars Neeb
- Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Uwe Reuter
- Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
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Barbanti P, Egeo G, Mitsikostas DD. Trigeminal‐Targeted Treatments in Migraine: Is 60% the Magic Number? Headache 2019; 59:1659-1661. [DOI: 10.1111/head.13635] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2019] [Indexed: 12/17/2022]
Affiliation(s)
- Piero Barbanti
- Headache and Pain Unit Department of Neurological, Motor and Sensorial Sciences IRCCS San Raffaele Pisana Rome Italy
- San Raffaele University Rome Italy
| | - Gabriella Egeo
- Headache and Pain Unit Department of Neurological, Motor and Sensorial Sciences IRCCS San Raffaele Pisana Rome Italy
| | - Dimos D. Mitsikostas
- First Neurology Department School of Medicine Aeginition Hospital National & Kapodistrian University of Athens Athens Greece
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84
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Olesen J, Ashina M. Calcitonin gene-related peptide - beyond migraine prophylaxis. Nat Rev Neurol 2019; 15:562-564. [PMID: 31488896 DOI: 10.1038/s41582-019-0258-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Jes Olesen
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
| | - Messoud Ashina
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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85
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86
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Abstract
Calcitonin gene-related peptide (CGRP) is a neuropeptide of importance in migraine pathogenesis. Its central role in migraine was proven pharmacologically by the development of CGRP receptor antagonists. Monoclonal antibodies targeting CGRP or its receptor are effective in the preventive treatment of episodic and chronic migraine and are considered potential breakthroughs in their treatment. Fremanezumab (previously known as TEV-48125, LBR-101, or RN-307) is a humanized IgG2a monoclonal antibody that binds to CGRP. The development of this antibody validated the role of CGRP in chronic migraine and the drug has been recently approved in the US by the FDA, while it continues to be reviewed by other regulatory agencies. Herein we provide an in-depth review of its development. We start by summarizing its in vitro and in vivo pharmacology, and the phase I studies. We then review the late-stage clinical development, with a focus on its efficacy, safety, similarities, and uniqueness relative to other CGRP antibodies. We close by discussing lessons learned on the mechanisms of migraine and areas for future development and exploration.
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